Trauma, Urgent Care, and Patient Safety

From Critical Care Medicine and Trauma, sponsored by the University of California, San Francisco, School of Medicine

Educational Objectives

The goals of this program are to improve perioperative management of cardiac surgery patients, to review procedures for ensuring patient saftey, and to raise awareness of issues of cost containment in trauma and critical care. After hear­ing and assimilating this program, the clinitian will be better able to:

1.   Explain why patients on b-blockers should not stop taking them perioperatively.

2.   Discuss the pros and cons of patient safety measures.

3.   Describe the risks and benefits of a “no blame” approach to medical errors.

4.   List some proven methods for reducing critical care costs, including early and appropriate nutrition, and greater use of weaning protocols and specialized units.

5.   Name the most expensive critical care injuries.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning commit­tee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any iden­tified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and the planning committee reported nothing to disclose.

Acknowledgements

This program was recorded at Critical Care Medicine and Trauma, held May 28-30, 2009, in San Francisco, CA, and sponsored by the University of California, San Francisco, School of Medicine. The Audio-Digest Foundation thanks the speakers and the Univer­sity of California, San Francisco, School of Medicine, for their cooperation in the production of this program.

Perioperative b-blockers: What Now?

Annemarie Thompson, MD, Assistant Professor of Anesthesia and Medicine, Vanderbilt University Medical Center, Nashville, TN

Indications for b-blockers: hypertension, arrhythmias, angina, coronary artery disease, acute coronary syndromes, congestive heart failure (CHF), postmyocardial infarction, and perioperative prevention of cardiac events in noncar­diac surgery

Hypertension: role as sole first-line agent controversial; multiple studies fail to demonstrate reduction in mortality or stroke over other antihypertensive agents; in studies that show benefit, b-blocker often combined with other agent; better monotherapy choices include diuretics, calcium channel blockers, and renin-angiotensin-aldosterone system (RAAS) blockers; in recent meta-analysis, b-blockers conferred no survival benefit over placebo

Primary prevention of myocardial infarction (MI): effect of b-blockers equal to that of other agents; b-blockers associated with 20% to 30% higher incidence of stroke than diuretics, calcium channel blockers, or RAAS inhibi­tors

Congestive heart failure: 35% reduction in total mortality associated with selected b-blockers in randomized con­trolled trials (RCTs); currently recommended for all patients with reduced left ventricular ejection fraction and symptoms of heart failure;  b-blockers cornerstone of neurohormonal regulation essential for reducing mortality from CHF; perioperative and hospital settings  —  in multicenter study of hospitalized patients with CHF, mortality at 60 to 90 days twice as high among patients withdrawn from  b-blockers, compared to patients who continued them; now recommended that patients stay on b-blockers

Perioperative use

Dutch Echocardiographic Risk Evaluation Applying Stress Echocardiography (DECREASE) study: 59 of 173 pa­tients with inducible ischemia scheduled for high-risk vascular surgery randomized to receive bisoprolol >1 wk before; were compared to 53 patients receiving standard care (no b-blocker); study stopped at first interim analy­sis because no nonfatal MIs occurred in bisoprolol group; only 2 patients died of cardiac causes, compared to 9 cardiac deaths and 9 nonfatal MIs in placebo group; overall combined end point of nonfatal MI or cardiovascular death was 3.4% in bisoprolol group, 34% in control group; authors concluded perioperative b-blockade can save patients at high risk for perioperative ischemia and MI; study criticized (patients should have been on b-blockers to begin with; study small)

Perioperative Ischemic Evaluation (POISE) trial: enrolled >8,000 high-risk patients (b-blocker-naive) undergoing major vascular surgery; 4100 patients randomized to receive 100 mg long-acting metoprolol 2 hr before surgery, 100 mg 6 hr after surgery, 200 mg 12 hr later, then 200 mg daily for 30 days; patients unable to take oral meto­prolol after surgery received 15 mg of metoprolol intravenously (IV) every 6 hr; control group received placebo; results  —  combined end points of cardiovascular death, nonfatal MI, and nonfatal cardiac arrest lower among pa­tients on metoprolol, but total mortality higher; fatal and nonfatal strokes in metoprolol group double that in pla­cebo group;  incidence of atrial fibrillation lower among patients on metoprolol; of 60 strokes in metoprolol group, 49 ischemic (possible hypotensive component), 3 hemorrhagic, and 8 uncertain; 15% of patients had his­tory of stroke before study; observations  —  high starting dose of metoprolol may have contributed to high stroke rate; blood pressure (BP) may have dropped too low; drug not titrated before surgery; IV dosing may have con­tributed to stroke; hemodynamic parameters for holding postoperative doses may have been too low (systolic BP <100 mm Hg); “if you’re using perioperative b-blockers, please titrate your doses”

Conclusions: b-blockers no longer considered first-line antihypertensives; do not withdraw b-blockers periopera­tively (may lead to rebound tachycardia or other conditions that induce ischemia); some “fairly strong evidence” supports b-blocker use for heart failure or post-MI; evidence “in the middle” for acute coronary syndromes, stable angina, perioperative use, and hypertrophic cardiomyopathy

Patient Safety in 2009

Robert M. Wachter, MD, Professor and Associate Chair, Department of Medicine, University of California, San Francisco, School of Medicine, and Chief of Medical Services, UCSF Medical Center

Beginning of patient safety movement: Institute of Medicine report, “To Err is Human,” released December, 1999; said number of patients killed by medical errors in United States equal to daily jumbo jet crash

Evolution of thinking on patient safety: 40 yr ago, internists had to learn 12 drugs; today, they learn 400; medicine has become too complex for clinicians simply to rely on own skills to prevent errors; systems thinking  —  creation of systems to anticipate and prevent errors

Regulation and accreditation: readback  —  Joint Commission on Accreditation of Health Care Organizations (JCAHO) established requirement in 2004 that prescriptions or critical test results reported by telephone be read back by person taking call; surgeons also required to sign surgical site; regulations help standardize practices; JCAHO now visits hospitals unannounced; disadvantage of regulations  —  difficult to regulate factors such as team­work, communication, and information technology; “a little too blunt to work for more sophisticated and nuanced problems”; starting to become “less important and increasingly burdensome”

Reporting systems: concept that reporting has intrinsic value flawed; point is to use information to elicit change; ability to react to reports may have been overestimated

Public reporting: biggest surprise is simple reporting leads to major improvement in quality; driven more by shame among hospitals than by consumer choice (no evidence that patients use data to choose hospitals); no good way of measuring errors in medication, diagnosis, or transition handoffs; exception  —  health care-associated infec­tions; explains why infections have become priority for those working in patient safety; other types of errors may take higher toll, but are harder to quantify; data usually collected from voluntary incident reports; hard to know if number should go up (suggesting more conscientious reporting) or down (suggesting fewer events to report); “never” events  —  events that should never happen; developed by National Quality Forum; reporting mandatory in 27 states; California requires report within 1 mo of event, along with remedial steps taken; hospitals must quickly determine what happened and why, and solve problem; promotes internal change; open question whether enhanced state enforcement helpful, harmful, “or a little bit of both”

Reimbursement: diagnosis-related group (DRG) system used to pay hospital one amount if case uncomplicated, 30% more if complication arises; policymakers determined some complications iatrogenic or preventable; start­ing in 2008, Centers for Medicare and Medicaid Services (CMS) began withholding extra reimbursement for “never” events; anticipated savings $23 million; savings relatively low because rule enforced only if error-related complication patient’s sole complication (rarely happens); conditions for which CMS will withhold reimbursement  —  catheter-associated urinary tract infections; Staphylococcus aureus bloodstream infections; se­vere decubitus ulcers; injury from fall; postoperative deep venous thrombosis and pulmonary embolism; key issues  —  must determine if patient had problem at admission; definitions must be standardized; preventability (condition may not be preventable, even with optimal care)

Information technology: costs more than budgeted; benefits overstated; literature now emerging about problems and new kinds of errors introduced by technology; 2009 stimulus package contains $19 billion to promote information technology; ultimately, hospitals will be more computerized than before, “and that to me is healthy”

Accountability: mantra in safety field has been “no blame”; some observers think lack of accountability helps ex­plain slow progress in patient safety; one camp maintains that most errors committed by competent, caring people; shaming and finger-pointing only stifles discussion; other states that system produces unsafe, low-quality care due to lack of incentive to do anything else; last 8 to 9 yr have seen variety of quality initiatives to create accountability; approaches must be reconciled; example  —  clinicians should be penalized for failing to wash hands; no blame “a tactic to achieve ends for which we will be held accountable”

How Will We Pay for Trauma and Critical Care?

A. Sue Carlisle, MD, PhD, Professor of Anesthesia and Medicine, University of California, San Francisco, School of Medicine

Cost of critical care: about one-sixth of gross national product and rising; percentage of hospital beds becoming crit­ical care beds increasing globally; at University of California, San Francisco (UCSF) medical center, number of critical care beds has risen from 30 to 60 within 7 to 8 yr; cost increasing while resources decreasing (Medicare “is running out of money”; Medicaid threatened with cuts daily; MediCal [California portion of Medicaid] being cut due to state budget crisis); reimbursement from private insurers decreasing

Factors contributing to cost of critical care: personnel  —nurses, respiratory therapists, physical therapists, pharma­cists, dietitians, physicians, and support staff all necessary to care for critically ill patients; newer drugs  —  examples include new antibiotics and clotting factors (eg, factor VIIa); newer devices  —  Wound Vacuum As­sisted Closure (VAC) thought to improve outcomes, but expensive to purchase and maintain; replacement re­quires operative procedure; other devices such as brain oximeter, jugular venous catheter, and therapeutic hyperthermia systems also improve outcomes, but are expensive; also require more time from nurses and phy­sicians; complications  —  lead to increased length of stay (LOS) and require more use of expensive drugs and interventions

Cost of infections: includes infections associated with central lines, ventilator-associated pneumonia, and sepsis; 1994 study estimated mortality attributable to complications at 35%; among survivors, every complication added $40,000 to intensive care unit (ICU) bill; another study estimated cost of being in medical cardiac unit at nearly $4000 per patient; in 2006 Canadian study, mortality rate from infections 50% lower than in United States, and cost »25% of that in United States; some study aspects questionable

Areas of cost containment: early appropriate nutrition  — improves outcomes, reduces LOS, and lowers costs; wean­ing protocols reduce LOS; involves avoiding oversedation (facilitates weaning, avoids complications of overseda­tion, and lowers cost of drugs); specialized units  —  eg, stroke units; improve efficiency, which lowers costs; also improve outcomes; decreasing transfusion threshold to hemoglobin 7 g/dL saved »$821.1 million per year in one ICU (direct costs only); use of step-down units  —  leaving carefully selected patients in postanesthesia care unit (PACU) until ready to go to floor, instead of sending them from PACU to ICU to floor bed; use of intensivists, mul­tidisciplinary teams, and closed units  —  pharmacists can guide clinicians in proper selection and timing of drugs; end-of-life decisions  —  costs of ICU care greatly increased by “not being willing to make very hard decisions”

Methods of payment: vary across hospitals; private insurers  —  pay for most care in private hospitals; as population ages, more people rely on Medicare; as fewer people can afford private insurance, more turn to Medicaid; costs of both programs rising, as is cost of delivering care; payments received from federal government “stable or falling”; private insurance important in academic settings, but reimbursement also comes from Medicare, Medicaid, and state funds; in California  —  state funding pays very small fraction of costs of running UCSF Medical Center; pub­lic hospitals (eg, San Francisco General Hospital [SFGH]) gets almost no private insurance payments; depend largely on state and federal funding; patient population different, with problems different from those with private insurance

Trauma centers: require 24/7 readiness (many staff members sleep in hospital or are on call from home); in 2004 study of 10 trauma centers, cost of 24-hr physician coverage alone estimated at $2.7 million per trauma center per year; other costs include higher laboratory, blood bank, and equipment costs; at SFGH, number of stab and gunshot wounds increasing steadily since 2003; care may cost $10,000 to >$600,000 per patient; average charge per patient $100,000 (does not include costs of caring for patients with other forms of trauma, such as falls); me­dian charges to care only for patients with stabbing and gunshot wounds over 1 yr at SFGH, $33 million; traffic injuries  —  in 2001, associated costs in San Francisco exceeded $800 million; in United States, annual costs of pedestrian injuries estimated at $11 billion; to reduce costs of critical care, must reduce incidence of interper­sonal violence, automobile accidents, and pedestrian injuries

Costs of complications: according to University of Michigan study, median charge for uncomplicated ICU care $33,000; with 1 minor complication (eg, urinary tract infection), cost »$82,000; with major complication (eg, pneumonia), cost »$151,000; conclusion  —  reducing complications will reduce costs of critical care

Trauma activation fees: often underbilled; if billed appropriately, can improve bottom line

Conclusions: cut costs and improve efficiency by improving access decisions, including better triage to appropriate level of care; improve end-of-life decisions to avoid excessive spending “when it really does not benefit patients or society”

Suggested Reading

Alonso-Coello P et al: Should physicians initiate beta-blocker therapy in patients undergoing non-cardiac surgery? Insights from the POISE trial. Pol Arch Med Wewn 118:616, 2008; Bangalore S et al: A meta-analysis of 94,492 patients with hyper­tension treated with beta blockers to determine the risk of new-onset diabetes mellitus. Am J Cardiol 100:1254, 2007; Botti M et al: Examining communication and team performance during clinical handover in a complex environment: the private sector post-anaesthetic care unit. Med J Aust 190:S157, 2009; Collins ME et al: On the prospects for a blame-free medical culture. Soc Sci Med September 17, 2009 [Epub ahead of print]; Devereaux PJ et al: Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet 371:1839, 2008; Millar M: Are national targets the right way to improve infection control practice? J Hosp Infect August 20, 2009 [Epub ahead of print]; Nuckols TK et al: Comparing process- and outcome-oriented approaches to voluntary incident reporting in two hospitals. Jt Comm J Qual Patient Saf 35:139, 2009; Pittet D et al: Nosocomial bloodstream infection in critically ill patients. Excess length of stay, extra costs, and attributable mortality. JAMA 271:1598, 1994; Poldermans D et al: The effect of bisoprolol on perioperative mortality and myocardial infarction in  high-risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. N Engl J Med 341:1789, 1999; Pronovost PJ et al: The wisdom and justice of not paying for “preventable complications.” JAMA 299:2197, 2008; Spoerke N, Martindale R: Should the principle of “pay for performance” be applied to nutrition support? Curr Gastroenterol Rep 11:332, 2009; Taheri PA et al: The cost of trauma center readiness. Am J Surg 187:7, 2004.